Senior Practicum Basic Physical Care
A client with terminal breast cancer is being cared for by a long-time friend who is a physician. The client has identified her sister as the agent in her health care power of attorney. The client loses decision-making capacity, and the sister tells the nurse, "A different physician will be caring for my sister now. I've dismissed her friend." In response, the nurse should:
abide by the wishes of the sister who holds the durable power of attorney. Explanation: A health care power of attorney transfers an individual's rights regarding health care decisions to the designated agent. It's within the power of the sister to change the physician caring for the terminally ill client. The dismissed physician has no power to interfere with the wishes of the health care power of attorney. It would be inappropriate and unprofessional of the nurse to ignore the wishes of the client's agent.
A client has a reddened area over a bony prominence. The nurse finds an unlicensed nursing personnel (UAP) massaging this area. The nurse should:
instruct the UAP that massage is contraindicated because it decreases blood flow to the area. Explanation: Massaging an area that is reddened due to pressure is contraindicated because it further reduces blood flow to the area. In the past, massaging reddened areas was thought to improve blood flow to the area, and some nursing personnel may still believe that massaging the area is effective in preventing pressure ulcer formation.
When changing the dressing on a pressure ulcer, a nurse notes necrotic tissue on the edges of the wound. Which action should the nurse anticipate that the physician will order?
Debridement Explanation: Necrotic tissue prevents wound healing and must be removed. This is accomplished by debridement. Incision and drainage, culture, or irrigation won't remove necrotic tissue. Incision and drainage drain a wound abscess. A wound culture indentifies organisms growing in the wound and helps the physician determine appropriate therapy. If the wound is infected, the physician may order irrigation — usually with an antibiotic solution — to treat the infection and clean the wound.
The nurse is caring for a client with a Jackson-Pratt drain. Which of the following would be the most appropriate action by the nurse?
Ensure that the drainage receptacles are kept compressed to maintain suction. Explanation: Portable wound drainage systems are self-contained and can be emptied and compressed to reestablish negative pressure, which promotes drainage. The other choices are incorrect because a Jackson-Pratt drain needs negative pressure in the bulb to promote drainage.
The health care provider prescribes furosemide 40 mg intravenous push daily. The medication comes in a vial of 50 mg/mL. Mark on the syringe the dosage of medication the nurse would give.
Explanation: Analyze to determine what information the question asks for, which is dose of furosemide to be given intravenously. Calculate the dosage in the following way: Using ratio proportion 50 mg : 1 ml :: 40 mg : x ml; 50 mg/ml = 40 mg/x ml; 40mg/50mg = 0.8 ml
Which of the following is the recommended nursing assessment to confirm placement of the nasogastric (NG) tube into the stomach of a client?
Obtain a chest X-ray and measure the pH of stomach contents. Explanation: A chest X-ray and pH that shows acidity are the only definitive diagnostic tools to confirm placement. The other choices are not best practice. Measuring the tube or using makings do not confirm placement, only approximate distance for insertion.
A nurse is completing the health history for a client who has been taking echinacea for a head cold. The client asks, "Why is this not helping me feel better?" Which response by the nurse would be the most accurate?
"There is limited information as to the effectiveness of herbal products." Explanation: At this time, there is no strong research evidence to warrant recommendations of herbal products for management of colds; further study is needed to show evidence of therapeutic effects and indications. Antibiotics are effective against bacteria; the head cold may have a viral cause. An uncomplicated upper respiratory tract infection subsides within 2 to 3 weeks. There may be a drug-drug interaction with herbal products and prescriptions.
The nurse at an outpatient surgical clinic witnesses client signatures. When obtaining signatures, which clients are able to sign their own consent for a procedure/surgery? Select all that apply.
-A 62-year-old with macular degeneration who is ordered a routine colonoscopy -A married 17-year-old who requires a cholecystectomy for relief of nausea and pain Explanation: There are many factors for the nurse to consider when evaluating whether a client can consent to surgery. These include being: mentally ill or disabled, a minor, under the influence of alcohol, drugs, or medication, in labor, under great stress or in pain at the time of consent, in a semi-conscious state. The 7 and 16 year old are minors while the 17 year old is married and an emancipated minor and able to give consent. Having difficulty seeing due to macular degeneration does not preclude the ability to have the consent read and then provide consent. Depending upon the severity of the dementia, the client will need to be evaluated for competence before independently providing consent.
While assessing the incision of a client who had surgery 2 weeks ago, a nurse observes that the suture line has a shiny, light pink appearance. Which step should the nurse take next?
Continue to monitor the suture line, and document findings. Explanation: During the fibrinoplastic stage of healing, granulation tissue, which has a characteristic pink shiny appearance, fills in the wound. This normal occurrence requires the nurse to continue to monitor the suture line. There is no evidence of wound dehiscence or necrotic tissue. There is also no indication that the wound is open or needs to be kept moist.
In anticipation of discharge, a nurse is teaching the daughter of an elderly woman how to change the dressing on her mother's venous ulcer. Which of the following teaching strategies is most likely to be effective?
Demonstrate and explain the procedure, and then have the daughter perform it. Explanation: All steps of a procedure such as a dressing change should be demonstrated, practiced, and provided in writing. The client or caregiver should then perform the procedure or treatment in the presence of the nurse to demonstrate his or her understanding and ability to carry out the procedure. This is more likely to facilitate success than providing a passive multimedia resource, explaining, or providing written instructions alone without reciprocal demonstration.
An obese, malnourished client has undergone abdominal surgery. While ambulating on the fourth postoperative day, she complains to the nurse that her dressing is saturated with drainage. Before this activity, the dressing was dry and intact. Which is the best initial action for the nurse to take?
Lift the dressing to assess the wound. Explanation: The client probably has a wound evisceration or dehiscence. The first step is to assess the wound; then the nurse can implement appropriate measures. Splinting the abdomen, applying an abdominal binder, or reinforcing the existing dressing would delay treatment.
Which assessment is most supportive of the nursing diagnosis, impaired skin integrity related to purulent inflammation of dermal layers as evidenced by purulent drainage and erythema?
Oral temperature of 101° F (38.3° C) Explanation: The nursing diagnosis indicates that the client's wound, which has purulent drainage, is infected. In response to the infection, the client's temperature would be elevated. A heart rate of 88 beats/minute, healing by primary intention, and a dry, intact dressing demonstrate normal assessment findings.
To reduce the risk of pressure ulcer formation, which activity should the nurse teach the client who is wheelchair-bound as a result of a spinal cord injury?
Shift your weight every 15 minutes. Explanation: The client who is wheelchair-bound with a spinal cord injury should be taught to make small weight shifts, lifting off the sacral area every 15 minutes. This decreases the risk of pressure ulcer formation. Bathing daily promotes skin cleanliness, but by itself will not prevent pressure ulcer formation. Eating a well-balanced diet that includes proteins and carbohydrates promotes good skin integrity. Moving from the bed to the wheelchair every 2 hours is not desirable because the client should not spend excessive amounts of time in bed. Pressure sores can develop in less than 2 hours.
The nurse unit manager is making rounds on a team of clients and notices a client who is wearing red slipper socks and a color-coded armband that indicates the client is at risk for falling walking down the hall unassisted. The client is already at the end of the hallway farthest from the client's room, but is not tired. What should the nurse do first?
Walk with the client back to his room, and assist him to get in bed. The client is identified as being at risk for falling, and a staff member or family member should accompany the client when walking. The nurse should first accompany the client back the room. Because the client is not fatigued, the client does not need a wheel chair, but must have assistance. The nurse can delegate the task of ambulating the client to the UAP, but it may take a while to locate one that it available at this time. Walking only in the room will not provide an opportunity for the client to gain strength and improve ambulation, but the nurse should remind the client to have assistance.
A nurse-manager in the office of a group of surgeons has received complaints from discharged clients about inadequate instructions for performing home care. Knowing the importance of good, timely client education, the nurse-manager should take which steps?
Work with the surgeons' staff and the nursing staff in the hospital and outpatient surgical center to evaluate current client education practices and make revisions as needed. Explanation: Every nurse who provides client care should provide client education. Nurses must work together to establish the best methods of educating clients. The most appropriate response is to contact the facility's nurse-manager, not the nursing staff. Evaluating client education in only the surgeon's office doesn't consider the entire client education process and all of the staff providing it. Client education is an important nursing responsibility and every complaint deserves attention.
A nurse should encourage a client with a wound to consume foods high in vitamin C because this vitamin:
enhances protein synthesis. Explanation: The client should be encouraged to consume foods high in vitamin C because vitamin C is essential for protein synthesis, an important part of wound healing. Hemostasis is responsible for the inflammatory response and reducing edema. Hemoglobin is responsible for oxygen transport.
The nurse uses Montgomery straps primarily so the client is free from:
skin breakdown. Explanation: The nurse uses Montgomery straps primarily to avoid the removal of long-term abdominal dressing tape and ultimate skin breakdown.
A client with severe chest pain is brought to the emergency department. The client tells the nurse, "I just have a little indigestion." How should the nurse respond?
"You seem concerned about your chest pain." Explanation: During a crisis, it's common for a client to use denial, a coping mechanism exhibited by minimizing symptoms or avoiding discussion. The nurse must respond therapeutically to the client. Confrontation about the client's statement and asking the client if he/she is confused are not therapeutic. Asking how having chest pain will change the client's life is not appropriate in this acute phase.
The nurse is caring for a client with a nasogastric tube who is due for an enteral feeding. Which of the following assessments by the nurse would indicate the need to withhold at this time? Select all that apply.
- Distention of the upper abdomen with vomiting -Material like coffee grounds noted in the nasogastric tube -Aspiration of milky contents and reports of nausea Explanation: The client has an order for enteral tube feedings. The aspiration of milky contents and reports of nausea would indicate that the prior feeding has not been tolerated or absorbed. Distention with vomiting would also indicate intolerance to the feeding. The presence of material that looks like coffee grounds indicates bleeding somewhere in the GI tract, thus feedings would be held. Watery contents upon aspiration with a pH of 5 and auscultation of air in the epigastric area when checking placement are normal and expected findings.
Which task should a nurse choose to delegate to a nursing assistant? Select all that apply.
- Taking a client's vital signs -Documenting a client's oral intake -Performing a blood glucose check Explanation: Registered nurses are responsible for all phases of the nursing process. These responsibilities include assessing a client's pain and evaluating a client's response to treatment. A nurse may delegate tasks such as taking vital signs, documenting intake and output, and performing blood glucose checks if she follows the five rights of delegation. The five rights of delegation include: right task (the task is within the delegate's scope of practice), right person (the person is competent to perform the task), right communication (the nurse gives the right directions to complete the task), right feedback (the nurse works collaboratively with the delegate), and right follow-up (the nurse follows-up on the task after it has been completed).
A nurse-manager identifies fall prevention as a unit priority. Which of the following actions can the nurses implement to meet these goals? Select all that apply.
- Use bed alarms to remind clients to call for help getting up -Maintain a clear path to client bathrooms -Make hourly rounds to client rooms Explanation: Client falls occur most often when there is need for assistance, but the client has not called for help. Frequent rounding, clear path to all bathrooms, and bed alarms for forgetful clients all have been shown to reduce client falls. Restraints should not be used without an order, or when a less-restrictive approach can be used. Closed doors at night will not reduce the risk for falls, but may increase them if the room is too dark or the nurses do not see the client in an unsafe situation.
A client is being transferred from the recovery room to the medical surgical nursing unit. The nurse from the recovery room should report which information to the nurse in the medical surgical unit? Select all that apply.
- type of surgery -current vital signs -amount of blood loss - fluids infusing including rate and type of fluid Explanation: Transfer reports must include information about the client's surgery, all current treatments and medications, vital signs, including pain level, fluid status including blood loss, and current IV infusions. It is not necessary to identify the surgeons who were present during the surgery or report the name of the insurance provider.
A client has a tumor of the posterior pituitary gland. The nurse planning his care would include which interventions? Select all that apply.
-Take daily weight. -Assess urine specific gravity. -Monitor intake and output. Explanation: Tumors of the pituitary gland can lead to diabetes insipidus because of a deficiency of antidiuretic hormone (ADH). Decreased ADH reduces the ability of the kidneys to concentrate urine, resulting in excessive urination, excessive thirst, and excessive fluid intake. To monitor fluid balance, the nurse would weigh the client daily, measure urine specific gravity, and monitor intake and output. The nurse would encourage fluids to keep intake equal to output and prevent dehydration. Coffee, tea, and other fluids that have a diuretic effect would be avoided.
The nurse is recording the intake and output for a client with the following: D5NSS 1,000 ml; urine 450 ml; emesis 125 ml; Jackson Pratt drain #1 35 ml; Jackson Pratt drain #2 32 ml; and Jackson Pratt drain #3 12 ml. How many milliliters would the nurse document as the client's output? Record your answer using a whole number.
654 Explanation: The nurse must add all the output volumes together: 450 ml + 125 ml + 35 ml + 32 ml + 12 ml = 654 ml; D5NSS 1,000 ml is considered input, not output.
After receiving information on various forms of birth control, a young couple decides to use a barrier method because they would like to try and conceive in 1 to 2 years. Which barrier method uses a rubber barrier to hold spermicide against the cervix?
A diaphragm. Explanation: A diaphragm is a dome-shaped device made from latex rubber that mechanically prevents semen from coming in contact with the cervix. It also holds a spermicidal jelly in place against the cervix. A condom rolls over an erect penis and collects the semen after ejaculation. A cervical cap is placed over the cervix and may be left in place for up to 3 days. A vaginal sponge contains spermicide and is a reservoir to hold the semen.
Which of the following circumstances likely requires the most documentation and communication by the nurse?
An older adult is being transferred from a subacute medical unit to a new long-term care facility following recovery from pneumonia. Explanation: Transfer from the hospital setting to a long-term care facility is likely to require significant documentation and communication from the nurses facilitating the transfer. This may include copying the chart or summarizing a large amount of relevant data. Transfers within a hospital typically require somewhat less documentation and communication, while discharges home or to an existing facility may not require a formal report of any type.
When preparing a client with a draining vertical incision for ambulation, where should a nurse apply the thickest portion of a dressing?
At the base of the wound Explanation: When a client is ambulating, gravity causes the drainage to flow downward. Covering the base of the wound with extra dressing will contain the drainage. Applying the thickest portion of the dressing at the top, in the middle, or over the total wound won't contain the drainage.
Which of the following food groups would be appropriate to suggest to a client who practices tenets of Islam?
Broiled chicken sandwich with skim milk Explanation: Members of the Islamic faith are forbidden to eat pork or drink alcohol.
A physician has ordered a heating pad for an elderly client's lower back pain. Which item would be most important for a nurse to assess before applying the heating pad?
Client's level of consciousness Explanation: A client who has impaired consciousness or altered mental status is at increased risk for injury from a heating pad. When administering a heat treatment, a nurse should always check the temperature of the heating unit and examine the client's skin for redness or irritation. Risk for falls, vital signs, and nutrition level are also important assessment areas, but they aren't the priority assessment for a client using a heating pad.
Indicate on the illustration where the nurse would place the other electrode of the automated external defibrillator (AED) on a victim who has collapsed and does not have a pulse.
Explanation: One electrode is placed to the right of the upper sternum just below the right clavicle. The other is placed, as shown, over the fifth or sixth intercostal space at the left anterior axillary line.
A nurse implements a health care facility's disaster plan. Which action should she perform first?
Identify a command center at which activities are coordinated. Explanation: During a disaster, having a command center to provide direction and coordinate activities is crucial. Cellular phones and pagers may be essential communication tools during a disaster. Essential off-duty personnel should respond to a disaster as quickly as possible. Admitted clients should be triaged and treated in accordance with the facility's triage policy.
The nurse finds an unlicensed assistive personnel (UAP) massaging the reddened bony prominences of a client on bed rest. The nurse should:
Instruct the UAP that massage is contraindicated because it decreases blood flow to the area. Explanation: Massaging areas that are reddened due to pressure is contraindicated because it further reduces blood flow to the area. The UAP should not massage the bony prominences or use lotion on the area. Massage does improve circulation and blood flow to muscle areas; however, because the area is reddened, the client is at risk for further skin breakdown.
A nurse must irrigate a gaping abdominal incision with sterile normal saline, using a piston syringe. How should she proceed?
Irrigate continuously until the solution becomes clear. To wash away tissue debris and drainage effectively, the nurse should irrigate the wound until the solution becomes clear. After irrigation, the nurse should dry the area around the wound; moistening this area promotes microorganism growth and skin irritation. When the area is dry, the nurse should apply a dry, sterile dressing rather than a wet-to-damp dressing. The nurse should always instill the irrigating solution gently. Rapid or forceful instillation can damage tissues.
When providing oral hygiene for an unconscious client, the nurse must perform which action?
Place the client in a side-lying position. Explanation: An unconscious client is at risk for aspiration. To decrease this risk, the nurse should place the client in a side-lying position when performing oral hygiene. Swabbing the client's lips, teeth, and gums with lemon glycerin would promote tooth decay. Cleaning an unconscious client's tongue with gloved fingers wouldn't be effective in removing oral secretions or debris. Placing the client in semi-Fowler's position would increase the risk of aspiration.
A client is admitted to the facility with a productive cough, night sweats, and a fever. Which action is most important in the initial care plan?
Placing the client in respiratory isolation Explanation: Because the client's signs and symptoms suggest a respiratory infection (possibly tuberculosis), respiratory isolation is indicated. Every 8 hours isn't frequent enough to assess the temperature of a client with a fever. Monitoring fluid intake and output may be required, but the client should first be placed in isolation. The nurse should wear gloves only for contact with mucous membranes, broken skin, blood, and other body fluids and substances.
An employer establishes a physical exercise area in the workplace and encourages all employees to use it. This is an example of which level of health promotion?
Primary prevention Explanation: Primary prevention precedes disease and applies to healthy clients. Secondary prevention focuses on clients who have health problems and are at risk for developing complications. Tertiary prevention focuses on rehabilitating clients who already have a disease or disability. Passive prevention enables clients to gain health as a result of others' activities without doing anything themselves.
A nurse manager observes bruises in the shape of finger marks around the elbows of an elderly, immobile client. The nurse should next:
Report this finding to the Adult Protective Services (APS). Explanation: Elderly clients are vulnerable to abuse. Bruising that is not located in areas typical for falls or bumps should be reported to the APS. The location and shape of this bruise are suggestive of abuse. The nurse taking care of this client and the physician should be alerted to the bruises after the APS is notified. The nurse should continue to assess the areas involved after notifying the APS.
A client complains of abdominal discomfort and nausea while receiving tube feedings. Which intervention is most appropriate for this problem?
Stop the feedings and check for residual volume. Explanation: Complaints of abdominal discomfort and nausea are common in clients receiving tube feedings. Stopping the feeding and checking for residual volume helps assess the reason for the client's nausea and discomfort. If residual volume is greater than 100 ml, hold the feeding and notify the physician. Feedings are normally given at room temperature to minimize abdominal cramping; however, this action doesn't help assess why nausea and discomfort are occurring. Elevating the head of the client's bed to at least 30 degrees prevents aspiration during feeding. Also, feeding containers are changed daily to prevent bacterial growth.
A nurse is giving a presentation to retirement home residents on fall prevention and injury reduction. Which of the following would be the most important priority?
Teaching about adjusting to change of position by sitting for a few minutes before standing to lessen dizziness Explanation: Sitting for a few minutes is the most appropriate to discuss to help maintain safety and reduce falls. Reliance on wheelchairs rather than mobility aids will result in weakening of the muscles and less strength and stability. The remaining actions would be important factors but not the immediate priority.
The nurse evaluates the effectiveness of the client's postoperative plan of care. Which outcome is expected for a client with an ileal conduit?
The client will empty the drainage pouch frequently throughout the day. Explanation: It is important that the client empty the drainage pouch throughout the day to decrease the risk of leakage. The client does not normally need to curtail physical activity. Aspirin should never be placed in a pouch because aspirin can irritate or ulcerate the stoma. The client does not catheterize an ileal conduit stoma.
The nurse is suctioning a client's tracheostomy. For what reason during the procedure does the nurse complete the above action?
To clear secretions from the tubing Explanation: The picture shows a nurse inserting the suction catheter in a container of water. The hole on the catheter is then occluded creating suction. The water is used to clear the catheter and tubing of secretions. The tubing does not need primed or lubricated. The catheter removes the secretions but does not loosen them.
When preparing to administer a tap water enema, in which position should the nurse place the client?
left Sims' Explanation: When administering an enema, the nurse should position the client in a left Sims position. Placing the client in this position facilitates the flow of fluid into the rectum and colon. It also allows the client to flex the right leg forward, adequately exposing the rectal area.
A client is being discharged with nasal packing in place. The nurse should instruct the client to:
perform frequent mouth care. Explanation: Frequent mouth care is important to provide comfort and encourage eating. Mouth care promotes moist mucous membranes. Nose drops cannot be used with nasal packing in place. When sneezing and coughing, the client should do so with the mouth open to decrease the chance of dislodging the packing. Gargling should not be attempted with packing in place.
A client on heparin for a deep vein thrombosis reports an aching pain in the back and finds it difficult to get comfortable when lying in that position. The client refuses to take any medications for pain. What actions would the nurse take to alleviate the back pain?
Provide lumbar support when in the supine position, offer a back rub, and check the possibility of heat treatments to relieve the pain. Explanation: It is important to respect the client's decision and to try other supportive measures to alleviate the pain.
Which action is contraindicated for a client who develops a temperature of 102° F (38.9° C)?
Providing a low-calorie diet Explanation: Because a client with a fever has an increased basal metabolism rate, he needs additional calories in his diet, not fewer calories. Monitoring the client's temperature, increasing his fluid intake, and covering him with a light blanket are therapeutic interventions for a fever.
The nurse is taking care of a client with Clostridium difficile. To prevent the spread of infection, what should the nurse do? Select all that apply.
- Wash hands with soap and water. -Wear a protective gown when in the client's room. Explanation: C. difficile is an organism that has developed very resistant and highly morbid strains. Universal precautions, most importantly handwashing, wearing personal protective gear, and modest use of antibiotics, are critical actions for stopping the spread. C. difficile is not spread via the respiratory tract; therefore, a mask is not needed. Alcohol-based hand sanitizers do not kill the spores of C. difficile; soap and water must be used. Sterile gloves are not needed to provide care; clean gloves may be worn.
The client is to receive antibiotic intravenous (IV) therapy in the home. The nurse should develop a teaching plan to ensure that the client and family can manage the IV fluid and infusion correctly and avoid complications. What should the nurse instruct the client to do? Select all that apply.
-Report signs of redness or inflammation at the site. -Call the health care provider (HCP) for a temperature above 100° F (37.8° C). - Cleanse the port with alcohol wipes. Explanation: When intravenous (IV) therapy must be administered in the home setting, teaching is essential. Written instructions, as well as demonstration and return demonstration help reinforce key points. The client and/or caregiver is responsible for adhering to the established plan of care that includes the treatment plan, monitoring plan, potential for complications, expected outcome/s, potential adverse effects, and plan for communicating with the HCP. Periodic laboratory testing may be necessary to assess the effects of IV therapy and the client's progress. The client should report signs of redness or inflammation that could indicate infection, and also report an elevated temperature. Prior to changing the fluids, the caregiver should cleanse the port with alcohol wipes. It is not necessary to use sterile gloves; the IV bag should be elevated to promote gravity flow.
A nurse-manager of an intensive care unit (ICU) can't be held legally responsible in a court of law for which action performed by the unit's staff?
A staff nurse refuses to follow a physician's order to administer medication because administering the dosage ordered could seriously harm the client. Explanation: The nurse-manager is legally responsible for actions that fall within the scope of practice of the staff members who perform them. A nurse may not knowingly administer or perform tasks that will harm a client. It's within a nurse's scope of practice to refuse to carry out such orders. A nurse-manager can't be held legally responsible for the nurse's refusal in this situation. Administering medications and initiating I.V. therapy aren't within the scope of practice for nursing assistants, and a staff nurse isn't licensed to fill prescriptions.The nurse-manager can be held legally responsible for these actions.
The nurse is observing a spouse administer eyedrops, as shown in the figure. What should the nurse instruct the spouse to do?
Administer the drops in the center of the lower lid. Explanation: The spouse has positioned the dropper and the client correctly to prevent injury to the client's eye. The spouse should administer the drops in the center of the lower lid. Following administration of the eyedrops, the client should blink the eyes to distribute the medication; squeezing or rubbing the eyes might cause the medication to drip out of the eye.
The nurse is caring for an unconscious intubated client with normal intracranial pressure. The nurse should:
Clean the mouth carefully, applying a thin coat of water-based lubricant, and moving the endotracheal tube to the opposite side daily. Explanation: The nurse must clean the unconscious client's mouth carefully, apply a thin coat of water-based lubricant, and move the endotracheal tube to the opposite side daily to prevent dryness, crusting, inflammation, and parotiditis. The unconscious client's temperature should be monitored by a route other than the oral (e.g., rectal, tympanic) because oral temperatures will be inaccurate. The client should be positioned in a lateral or semiprone position, not a supine position, to allow for drainage of secretions and for the jaw and tongue to fall forward. The client should not be dragged when turned, as may happen when a drawsheet is used. Care should be taken to lift the client's heels, buttocks, arms, and head off of the sheets when turning. Trochanter rolls, splints, foam boot aids, specialty beds, and so on—not just two pillows—should be used to keep the client in correct body position and to decrease pressure on bony prominences.
A nurse is required to irrigate a client's nasogastric tube, a procedure the nurse has not performed before. What is the most appropriate action by the nurse?
Contact the nurse educator for an in-service and support in performing the skill. Explanation: The nurse has a responsibility for recognizing his/her limitations and to seek assistance when necessary. Because the nurse has not performed this skill previously, the nurse educator is the appropriate person to provide inservice and support so the client receives safe and competent care. The other options are incorrect because they do not demonstrate expected behavior for a nurse who has identified a gap in his/her learning or expertise.
A physician has ordered penicillin G potassium I.V., for a client with a severe streptococcal infection. A nurse determines that the client may be allergic to penicillin. When considering best practice, what should the nurse's priority intervention be?
Holding the penicillin G potassium and notifying the physician that the client may have an allergy to penicillin Explanation: The nurse should hold the penicillin G potassium, even if the client isn't sure he's allergic to penicillin, and notify the physician so he may order a different antibiotic. Many clients can't act as their own advocates; they rely on nurses to protect their rights. An allergy to penicillin G potassium is suspected, but not comfirmed. Administering penicillin G potassium could cause a life-threatening reaction. Administering the medication, then watching for a reaction or notifying the pharmacist that a reaction might occur, isn't best practice. If a client is allergic to penicillin, a nurse should alert the pharmacist and label the client's chart appropriately.
What would be an appropriate action for the nurse prior to performing deep tracheal suctioning due to increased secretions?
Hyperoxygenate the client before suctioning. Explanation: Preoxygenation and deep breathing assist in reducing suction-induced hypoxemia because it decreases the risk of atelectasis caused by negative pressure of suctioning. Deflating the cuff is not necessary and there is no reason to instill acetylcysteine into the tracheotomy before suctioning. Pressure is applied only with the removal of the catheter.
The nurse applies warm compresses to a client's leg. To determine effectiveness of the compresses, the nurse should determine if there is:
Improved circulation to the area. Explanation: Heat applications cause vasodilation, which promotes circulation to the area, and increase tissue metabolism and leukocyte mobility. Heat applications do not prevent swelling; applications of cold are used to prevent swelling by causing vasoconstriction. Moist heat applications do not reduce bruising or scaling on the skin.
Which strategy can help make the nurse a more effective teacher?
Including the client in the discussion Explanation: An effective teacher always involves the client in the discussion. Using technical terms and providing detailed explanations usually confuse the client and act as barriers to learning. Using loosely structured teaching sessions permits distractions and deviations from teaching goals.
Eight farm workers are admitted to the emergency department after they were splashed with "a couple of chemicals" at work 30 minutes ago. They have watery/itchy eyes, slight cough, diaphoresis, constricted pupils, and are conscious and oriented. Their clothes are wet. What action should the nurse do first?
Isolate the clients. Explanation: Safety of the staff and others is the first priority. Isolating reduces the chance of contaminating others (secondary contamination). Vital signs can be obtained when it is safe—after protecting staff, clients, and visitors from secondary contamination. Oxygen is not indicated for any of the listed symptoms. Removing clothing is important to prevent further exposure to the client, but must be done in a safe manner to prevent secondary contamination to others. The clients can remove their own clothes and place them in plastic bags. After the safety of the staff and others is addressed, and the facility is prepared and properly trained staff is ready, the clients can be given a decontamination shower. If the staff is not trained, 911 may be the most appropriate response. Finding out which chemicals were involved is important, but does not take priority over preventing secondary contamination.
A client who's dehydrated has urinary incontinence and excoriation in the perineal area. Which action would be a priority?
Keeping the perineal area clean and dry Explanation: Because the skin, the body's first line of defense, is broken and excoriated, keeping the area clean and dry is a priority and promotes healing. Offering the urinal every 3 hours would help set a voiding schedule; however, to avoid incontinence, the urinal should be offered more often. Fluid intake of 1 L/day is insufficient for a client who has been diagnosed as dehydrated, and the fluids wouldn't aid healing. Continued incontinence as well as moist compresses would contribute to additional skin excoriation and breakdown.
The nurse is obtaining a health history from a client of Puerto Rican descent. Which of the following is most likely to be a health problem with a cultural connection for this client?
Lactose enzyme deficiency. Explanation: Common health problems that may affect the Puerto Rican population include lactose enzyme deficiency and parasitic diseases. Tuberculosis is a common health problem for the Native American population. Sickle-cell anemia predominantly affects the African-American population, and suicide is a common health problem for the Native American and white middle-class populations.
Which of the following actions most clearly demonstrates a nurse's commitment to social justice?
Lobbying for an expansion of Medicare eligibility and benefits. Explanation: Social justice is a professional value that encompasses efforts to promote universal access to healthcare, such as the expansion of publicly funded programs like Medicare. Culturally competent care is a reflection of human dignity while answering clients' questions and documenting accurately are expressions of the value of integrity.
A client is admitted to the healthcare facility with active tuberculosis (TB). The nurse should include which intervention in the care plan?
Putting on an individually-fitted mask when entering the client's room Explanation: Because TB is transmitted by droplet nuclei from the respiratory tract, the nurse should put on a mask when entering the client's room. Occupational Safety and Health Administration (OSHA/Canadian Centre for Occupational Health and Safety) standards require an individually-fitted mask. Having the client wear a mask at all times would hinder sputum expectoration and respirations would make the mask moist. A nurse who does not anticipate contact with the client's blood or body fluids need not wear a gown or gloves when providing direct care. A client with TB should be in a room with laminar airflow, and the room's door should be shut at all times.
A client who suffered a stroke has a nursing diagnosis of Ineffective airway clearance. The goal of care for this client is to mobilize pulmonary secretions. Which intervention helps meet this goal?
Repositioning the client every 2 hours Repositioning the client every 2 hours helps prevent secretions from pooling in dependent lung areas. Restricting fluids would make secretions thicker and more tenacious, thereby hindering their removal. Administering oxygen and keeping the head of the bed at a 30-degree angle might ease respirations and make them more effective but wouldn't help mobilize secretions.
A client who has had a bowel resection comes to the health center 7 days postoperatively for removal of the staples. As the nurse is cleansing the incision, the client reports of mid-incision pain. After removing three staples, the nurse observes that the incision is separating. What is the nurse's priority action?
Stop the staple removal, cover the incision, and report the findings to the physician. Explanation: If there are signs of dehiscence while removing staples, it is important to stop the removal of staples and to dress the open wound. It is very important to relay the observations of mid-incision pain and separation of the wound to the physician as soon as possible. Continuing the staple removal is not appropriate. A dehiscence presenting with other signs of pain could indicate the presence of an abscess. It is not enough to apply butterfly tapes. The observations need to be relayed to the physician.
Which is appropriate for the nurse to include in a plan for the prevention of pressure ulcers?
Systematic skin assessment at least once per shift Explanation: The best treatment for a pressure ulcer is prevention. If a client has been determined to be at risk for developing a pressure ulcer, a systematic skin assessment should be conducted at least once per shift. Other preventive measures include daily gentle cleaning of the skin and avoiding harsh soaps and hot water, which are damaging to the skin. Massage of bony prominences is not done because it can increase damage to the underlying tissue. The client should be encouraged to change position at least every 2 hours to avoid pressure on any one area for a prolonged period.
Indicate on the illustration the area that correctly identifies the position of the distal tip of a central line that is inserted into the subclavian vessel.
The distal tip of a central line lies in the superior vena cava or right atrium.
A nurse is providing home care to a client with a foot ulcer related to diabetes. The client needs daily insulin injections. Family caregivers do not possess the technical skills to inject insulin. Which of the following should the nurse keep in mind?
The nurse needs to be creative in integrating the technical and relational aspects of care. Explanation: The nurse needs to be creative in integrating the technical and relational aspects of care. The current reimbursement system does not recognize the family's nontechnical value priorities. Nurses are expected to educate the family caregivers to conduct the skilled task where possible. In this case, the nurse can teach the family caregivers to inject insulin. Family caregivers can be perceived to be nonsupportive of good care if the families do not follow through.
A nurse prepares to transfer a client from a bed to a chair. Which principle demonstrates safe body mechanics?
The nurse uses a rocking motion while helping the client to stand. Explanation: Rocking provides extra force when pushing or pulling. The nurse should keep any weight as close to her body as possible when lifting — not at arm's length. The nurse should keep her knees slightly bent and her feet spread apart to provide a wide base of support. Keeping the knees straight and stiff and bending at the waist and keeping the feet close together aren't examples of safe body mechanics. These positions could result in injury to the nurse or to the client.
A nurse-manager in the office of a group of surgeons has received complaints from discharged clients about inadequate instructions for performing home care. Knowing the importance of good, timely client education, the nurse-manager should take which steps?
Work with the surgeons' staff and the nursing staff in the hospital and outpatient surgical center to evaluate current client education practices and make revisions as needed. Explanation: Every nurse who provides client care should provide client education. Nurses must work together to establish the best methods of educating clients. The most appropriate response is to contact the facility's nurse-manager, not the nursing staff. Evaluating client education in only the surgeon's office doesn't consider the entire client education process and all of the staff providing it. Client education is an important nursing responsibility and every complaint deserves attention.
A client is admitted to the hospital. The graduate nurse is completing a nursing assessment and asks the client if he/she has an advanced directive. The client asks for an explanation of advanced directives. The registered nurse preceptor would intervene if she heard the graduate nurse inform the client that an advance directive is:
a legal document initiated by the physician to give the client "do not resuscitate" (DNR) status. Explanation: A facility refers to an advance directive, a document the client writes or completes, to provide care at a time when the client cannot make his/her own choices. The living will and health care proxy are both examples of advance directives. A living will is a document which a competent adult prepares and which provides direction regarding medical care if the client becomes incapacitated. Health care proxy is an authorization enabling any competent individual to designate someone else to exercise decision-making authority on the individual's behalf under specific circumstances.
A client has been unable to void since having abdominal surgery 7 hours ago. The nurse should first:
assist the client up to the toilet to attempt to void. Explanation: Urinary retention is common following surgery with anesthesia, following childbirth, or as a result of specific medication use, for example narcotics for pain. Clients should be assisted to an anatomically comfortable position to void prior to resorting to more invasive methods such as intermittent or indwelling catheterization to manage urinary retention. Difficulty voiding after child birth is expected, and it is not necessary to notify the HCP. While increasing fluid intake is important, it will not help the client void now.
When planning pain control for a client with terminal gastric cancer, a nurse should consider that:
clients with terminal cancer may develop tolerance to opioids. Explanation: Clients with cancer may develop a tolerance to opioids, causing them to need higher doses to provide adequate pain relief. Although a nurse should always remain alert for adverse effects of opioids, clients may develop a tolerance for these effects. Therefore, it isn't likely that higher doses would cause respiratory depression. Administering pain medication around the clock maintains steady blood levels of opioids. Sleeping doesn't necessarily indicate pain relief, especially in a client who has chronic pain.
A client is recovering from abdominal surgery and has a nasogastric (NG) tube inserted. The expected outcome of using the NG tube is gastrointestinal tract:
decompression. Explanation: After abdominal surgery, the reason for inserting a NG tube is to decompress the gastrointestinal tract until peristaltic action returns. Compression may be used to control bleeding esophageal varices. Lavage is used to remove substances from the stomach or control bleeding. Gavage is used to provide enteral feedings.
A nurse is assisting with a subclavian vein central line insertion when the client's oxygen saturation drops rapidly. He reports shortness of breath and becomes tachypneic. The nurse suspects the client has developed a pneumothorax. Further assessment findings supporting the presence of a pneumothorax include:
diminished or absent breath sounds on the affected side Explanation: In the case of a pneumothorax, auscultating for breath sounds will reveal absent or diminished breath sounds on the affected side. Paradoxical chest wall movements occur in flail chest conditions. Tracheal deviation occurs in a tension pneumothorax. Muffled or distant heart sounds occur in cardiac tamponade.
A client is admitted with peritonitis. The priority of nursing care for this client is:
fluid and electrolyte balance. Explanation: With peritonitis, fluids and electrolytes can sequestrate, raising central venous pressure. Shock and circulatory failure can occur, making management of fluid and electrolyte balance the primary focus of care. Pain management is important as the irritation does cause significant discomfort. However, pain can be treated and is not life threatening. Nutrition can become an issue as it relates to nausea/vomiting and increased metabolic needs of client with pancreatitis; nutritional issue needs to be addressed but are not life threatening and can be addressed along with or after fluid and electrolyte balance. Issues of anxiety result from situational crisis such as this client's current change in health status and will need to be addressed, but they are not life threatening.
A nurse is assessing a client for the risk of falls. The nurse should obtain:
gait and balance information. Explanation: Assessing the client's gait and balance helps determine his risk of falls. The facility's policy on restraints isn't relevant to a risk assessment for falls. Assessing the family's psychosocial history and determining the patient's home activity level are important but not as important as gait and balance in relation to the risk of falls.
The nurse is teaching an older adult how to prevent falls. The nurse should tell the client to:
instruct the client to rise slowly from a supine position. Explanation: Normal age-related changes can predispose older adults to falling and include vision, hearing, cardiovascular, musculoskeletal, and neurological changes. One of the most common problems facing older adults is the loss of tissue elasticity that affects the arteries. This loss of elasticity results in a decrease in tissue recoil and leads to changes in blood pressure with position changes. When they rise too quickly from a supine position, they feel light-headed and dizzy and can fall. The nurse should instruct clients to change positions slowly and to dangle the legs a few minutes when arising from a supine position. When aging, the lens of the eye becomes sensitive to very bright light which can causes a glare and visual disturbances that can lead to falls. Rooms should be well lit, but not with bright lights that cause a glare. Neurological changes are seen in impaired reflexes and thus postural instability. This loss of postural stability leads to falls. The need of assistive devices (hand rails, cane, walkers) helps reduce falls and promote independence. If joint pain develops and remains untreated, it can cause older adults to become sedentary or immobile. This disuse of muscles contributes to muscle weakness and falls. Nursing interventions should be directed at encouraging regular ambulation and joint movement (range of motion).
The nurse is preparing a 45-year-old female for a vaginal examination. The nurse should place the client in which postion?
lithotomy position Explanation: Although other positions may be used, the preferred position for a vaginal examination is the lithotomy position. This position offers the best visualization. If the client is elderly and frail, staff members may need to support the client's flexed legs while the examiner conducts the examination and obtains the Papanicolaou smear. Positioning the client in the other positions will make visualization more difficult and may not be as comfortable for the client.
A man of Chinese descent is admitted to the hospital with multiple injuries after a motor vehicle accident. His pain is not under control. The client states, "If I could be with my people, I could receive acupuncture for this pain." The nurse should understand that acupuncture in the Asian culture is based on the theory that it:
restores the balance of energy. Acupuncture, like acumassage and acupressure, is performed in certain Asian cultures to restore the energy balance within the body. Pressure, massage, and fine needles are applied to energy pathways to help restore the body's balance. Acupuncture is not based on a belief in purging evil spirits. Although pain relief through acupuncture can promote tranquility, acupuncture is performed to restore energy balance. In the Western world, many researchers think that the gate-control theory of pain may explain the success of acupuncture, acumassage, and acupressure.
The mother of a client who has a radium implant asks why so many nurses are involved in her daughter's care. She states, "The doctor said I can be in the room for up to 2 hours each day, but the nurses say they are restricted to 30 minutes." The nurse explains that this variation is based on the fact that nurses:
work with radiation on an ongoing basis, while visitors have infrequent exposure to radiation. Explanation: The three factors related to radiation safety are time, distance, and shielding. Nurses on radiation oncology units work with radiation frequently and so must limit their contact. Nurses are physically closer to clients than are visitors, who are often asked to sit 6 feet (182.9 cm) away from the client. Touching the client does not increase the amount of radiation exposure. Aseptic technique and isolation prevent the spread of infection. Age is a risk factor for people in their reproductive years.